BPCI models require a working relationship between inpatient and outpatient settings.
The federal Bundled Payments for Care Improvement (BPCI) initiative links reimbursement of services rendered within a 90-day episode of care. Participating organizations agree to enter into agreements that include measurements of quality and financial accountability. The objective is to increase quality of care while decreasing costs to Medicare.
The equation can be simplified to this: spending that is below the allotted amount is returned to the organization if the objective is achieved. Spending above the allotted amount is recovered at a percentage by the Centers for Medicare & Medicaid Services (CMS) from the organization that entered into the BPCI agreement.
According to the LewinGroup CMS report (June 2020), initial results cite successful measures of participation, yet the evaluation for the impact on payment, utilization, and quality of care is still being researched. The Innovation Center with CMS has provided a toolkit for success; however, the practicality of changing the culture of hospital systems and physician mindsets comes with its own set of challenges.
BPCI models require a working relationship between inpatient and outpatient settings. The tactics used by organizations that participate in the bundled payment program need to be determined by the individual facilities. Involvement of community resources, communication with the patient, and a seamless transition from the inpatient setting to the outpatient setting will be critical for financial success and improvement to care delivery. Below is a list of some key components that could improve quality outcomes for BPCI patients.
Oversight Steering Committees
BPCI is an all-in approach. That means regardless of who signed up for the arrangement, the physician groups, care management teams, Accountable Care Organization (ACO), and/or hospitals all must ensure alignment. Setting up an oversight committee with subgroups to evaluate the transparency of cost per case, quality indicators, and strategies to address the 90-day coverage period are vital to success. A task force and collaborative working groups of those involved in the BPCI program can help evaluate program performance and come up with strategies for process improvement. Regular meetings with key stakeholders, including the post-acute providers, are imperative to ensure a smooth transition of care with improved quality and decreased risk for readmission. Data analysis of the spending to net ratio on a quarterly review basis will assist to illuminate the program strengths and weaknesses.
A Wide Net for Patient Identification
The use of a risk assessment tool in the electronic medical record (EMR) will help to define risk stratification at the start of each patient episode. Use of the clinical documentation improvement (CDI) team can help identify likely BPCI participants during the medical record review process, and alert the care team early during a hospitalization. This logic can also be built within the EMR to flag possible patients for the care team. Since identification is difficult to confirm until coding is complete, a wide net for potential members should be cast by the medical team and should be discussed during care conferences and rounding.
Risk Stratification & Preparation
The development and use of a risk stratification tool is essential to identify the highest-risk patients who will require the most resources during and after the inpatient stay. It is also important to have a tool or tools to identify patients at high risk for readmissions. An unnecessary readmission for a BPCI patient is costly to the 90-day coverage period. Avoiding this with a safe discharge plan will decrease cost and improve quality measures for the hospital. Most electronic medical record systems such as Epic and Cerner have a built-in tool that helps identify the most high-risk patient DRGs and readmissions. Individual facilities may need to also develop processes or tools that identify risk assessments during all phases of the stay.
For elective surgeries, initial assessments should be completed prior to the admission for surgery. Pending the BPCI arrangement, this can be completed by the medical group in the office, using a trained medical assistant, or by the hospital care management team. Questions to be asked during an assessment, prior to admission, can assist to identify unforeseen discharge barriers. This will also help the patient clearly understand their active role in successfully navigating care. The amount of work that can be completed prior to the hospitalization will streamline the in-hospital process and length of stay.
Another imperative process in risk stratification is daily rounding on the units, which ideally would include the hospitalist team caring for the patients. Daily rounding ensures that discharge planning begins on the day of admission. Daily rounds should occur on the nursing units and include the case manager, therapy, and the floor nurse who is caring for each patient. The charge nurse should also attend on each unit to help orchestrate the rounds and ensure that each floor nurse is included to discuss their patients. Daily rounding on ICU or at a Level One trauma hospital should always include the physicians, to allow for discussion of changes in the patient's status.
A daily rounding tool should include the use of the multidisciplinary team to focus on the needs of the patient at discharge. Including therapy services in the rounds gives the team an opportunity to discuss the most appropriate discharge plan for the patient. Daily rounds also give the team an opportunity to continue to discuss the plan, which may continue to change as the patient’s status improves. As the cost of medications continue to rise, some hospitals have begun to include pharmacists in their daily rounding. Pharmacists can assist in discussions regarding medications needed for discharge and the possibility for less expensive drugs that can have the same effect, therefore improving the BPCI cost savings for the episode.
Challenges for Systems Enrolled in BPIC Programs
The need to leverage post-acute care partnerships to share the financial accountability of the episode of care has a vital role in the BPCI model. Revenue for the encounter is tracked for 90 days from the start of care. The partners caring for the patient need to be compliant with the requirements for quality and cost. A partnership with a low-quality post-acute facility can jeopardize success. Unnecessarily high costs or prolonged length of stays can impact the margin for the organizations to turn a profit on the episode, or possibly the need to repay Medicare for a portion of the services rendered. Including the post-acute executives in steering committees, highlighting their data and performance, can help alleviate some of these challenges.
Health systems also need to manage factors that will affect the patient while they are still in the acute-care setting, and for patients that are expected to discharge to home. A high cost factor to consider is the price of medications and the importance of the patients adhering to their discharge medications. As mentioned, many hospitals have begun to include a pharmacist in their daily rounding to assess for the appropriateness of prescribed medications and to ensure that patients discharge with not only the appropriate medications, but also the most cost-effective ones. Adherence to medications after discharge can be unpredictable, depending on the patient’s compliance and the ability to understand the need. An outpatient case management program that calls the patient after discharge can assist with medication adherence and troubleshoot or triage any post-acute needs that arise.
BPCI has multiple approaches of how to tackle the challenge of reducing cost while improving quality. CMS’s Innovation Center is begging for participating organizations to think beyond the acute episode and challenge the care continuum for process improvement. Regardless of who initiates the program, the patient’s circle of care requires collaborative participation with physicians that are willing to openly examine performance and spending. Including additional team members such as pharmacists, care managers, and post-acute providers will create a more cohesive presence to address cost demands and barriers to improved quality.